Current through Register Vol. 35, No. 18, September 24, 2024
MAD covers services and procedures that are medically
necessary for the diagnosis and treatment of an illness or injury as indicated
by the MAP eligible recipient's condition. All services must be furnished
within the limits of provider program rules and within the scope of their
practice board and licensure.
A.
Medical practitioner services:
(1) Second surgical opinions: MAD covers
second opinions when surgery is considered.
(2) Services performed in an outpatient
setting: MAD covers procedures performed in the office, clinic or as outpatient
institutional services as alternatives to hospitalization. These procedures are
those for which an overnight stay in a hospital is seldom necessary.
(a) A MAP eligible recipient may be
hospitalized if they have existing medical conditions that predispose them to
complications even with minor procedures.
(b) Claims may be subject to pre-payment or
post-payment review.
(c) Medical
justification for performance of these procedures in a hospital must be
documented in the MAP eligible recipient's medical record.
(3) Noncovered therapeutic radiology and
diagnostic imaging services: MAD does not pay for kits, films or supplies as
separate charges. All necessary materials and minor services are included in
the service or procedure charge. Reimbursement for imaging procedures includes
all materials and minor services necessary to perform the procedure. MAD does
not pay an additional amount for contrast media except in the following
instances:
(a) radioactive isotopes;
(b) non-ionic radiographic contrast material;
or
(c) gadolinium salts used in
magnetic resonance imaging.
(4) Midwives services: MAD covers services
furnished by certified nurse midwives or licensed midwives within the scope of
their practice, as defined by state laws and rules and within the scope of
their practice board and licensure. Reimbursement for midwife services is based
on one global fee, which includes prenatal care, delivery and postpartum care.
(a) Separate trimesters completed and routine
vaginal delivery can be covered if a MAP eligible recipient is not under the
care of one provider for the entire prenatal, delivery and postpartum
periods.
(b) MAD covers laboratory
and diagnostic imaging services related to pregnancy. These services can be
billed separately.
(c) MAD covers
gynecological or obstetrical ultrasounds without requiring a prior
authorization of any kind.
(d) MAD
covers a MAP eligible pregnant recipient's labor and delivery services at a New
Mexico department of health (DOH) licensed birth center through the "Birthing
Options Program" (BOP). MAD reimburses the birth center facility and the
rendered services of a midwife separately. BOP services are provided by an
eligible midwife that enrolls as a BOP provider with the human services
department/medical assistance division (HSD/MAD). The facility must comply with
all DOH licensing requirements, including limiting licensure. The facility must
maintain all clinical documentation, including schedules, for the period of
time as required under 8.302.1 NMAC. The program does not cover the full scope
of midwifery services nor replace pediatric care that should occur at a primary
care clinic.
(e) Non-covered
midwife services: Midwife services are subject to the limitation and coverage
restrictions which exist for other MAD services. MAD does not cover the
following specific services furnished by a midwife:
(i) oral medications or medications, such as
ointments, creams, suppositories, ophthalmic and otic preparations which can be
appropriately self-administered by the MAP eligible recipient;
(ii) services furnished by an apprentice;
unless billed by the supervising midwife;
(iii) an assistant at a home birth unless
necessary based on the medical condition of the MAP eligible recipient which
must be documented in the claim.
B.
Pharmaceutical, vaccines and other
items obtained from a pharmacy: MAD does not cover drug items that are
classified as ineffective by the food and drug administration (FDA) and
antitubercular drug items that are available from the public health department.
In addition, MAD does not cover personal care items or pharmacy items used for
cosmetic purposes only. Transportation to a pharmacy is not a MAD allowed
benefit with the exception for justice-involved MAP eligible recipients who are
released from incarceration at a correctional facility within the first seven
days of release.
C.
Laboratory and diagnostic imaging services: MAD covers medically
necessary laboratory and diagnostic imaging services ordered by primary care
provider (PCP), physician assistant (PA), certified nurse practitioner (CNP),
or clinical nurse specialists (CNS) and performed in the office by a provider
or under his or her supervision by a clinical laboratory or a radiology
laboratory, or by a hospital-based clinical laboratory or radiology laboratory
that are a enrolled MAD provider. See
42 CFR Section
440.30.
(1)
MAD covers interpretation of diagnostic imaging with payment as follows: when
diagnostic radiology procedures, diagnostic imaging, diagnostic ultrasound, or
non-invasive peripheral vascular studies are performed in a hospital inpatient
or outpatient setting, payment is made only for the professional component of
the service. This limitation does not apply if the hospital does not bill for
any component of the radiology procedures and does not include the cost
associated with furnishing these services in its cost reports.
(2) A provider may bill for the professional
components of imaging services performed at a hospital or independent radiology
laboratory if the provider does not request an interpretation by the hospital
radiologist.
(3) Only one
professional component is paid per radiological procedure.
(4) Radiology professional components are not
paid when the same provider or provider group bills for professional components
or interpretations and for the performance of the complete procedure.
(5) Professional components associated with
clinical laboratory services are payable only when the work is actually
performed by a pathologist who is not billing for global procedures and the
service is for anatomic and surgical pathology only, including cytopathology,
histopathology, and bone marrow biopsies, or as otherwise allowed by the
medicare program.
(6) Specimen
collection fees are payable when obtained by venipuncture, arterial stick, or
urethral catheterization, unless a MAP eligible recipient is an inpatient of a
nursing facility or hospital.
(7)
Noncovered laboratory services: MAD does not cover laboratory
specimen handling, mailing, or collection fees. Specimen collection is covered
only if the specimen is drawn by venipuncture, arterial stick, or collected by
urethral catheterization from a MAP eligible recipient who is not a resident of
a NF or hospital. MAD does not cover the following specific laboratory
services:
(a) clinical laboratory professional
components, except as specifically described under covered services
above;
(b) specimens, including pap
smears, collected in a provider's office or a similar facility and conveyed to
a second provider's office, office laboratory, or non-certified
laboratory;
(c) laboratory specimen
handling or mailing charges;
(d)
specimen collection fees other than those specifically indicated in covered
services; and
(e) laboratory
specimen collection fees for a MAP eligible recipient in NF or inpatient
hospital setting.
D.
Reproductive health services:
MAD pays for family planning and other related health services (see
42
CFR Section 440.40(c)) and
supplies furnished by or under the supervision of a MAD enrolled provider
acting within the scope of their practice board or licensure.
(1) Prior to performing medically necessary
surgical procedures that result in sterility, providers must complete a
"
sterilization consent" or a "
hysterectomy
acknowledgment/consent" form. MAD covers a medically necessary
sterilization under the following conditions. See
42
CFR Section 441.251 et seq:
(a) a MAP eligible recipient 21 years and
older at the time consent is obtained;
(b) a MAP eligible recipient is not mentally
incompetent; mentally incompetent is a declaration of incompetency as made by a
federal, state, or local court; a MAP eligible recipient can be declared
competent by the court for a specific purpose, including the ability to consent
to sterilization;
(c) a MAP
eligible recipient is not institutionalized; for this section,
institutionalized is defined as:
(i) an
individual involuntarily confined or detained under a civil or criminal statute
in a correctional or rehabilitative facility, including a psychiatric hospital
or an intermediate care facility for the care and treatment of mental
illness;
(ii) confined under a
voluntary commitment in a psychiatric hospital or other facility for the care
and treatment of mental illness;
(d) a MAP eligible recipient seeking
sterilization must be given information regarding the procedure and the results
before signing a consent form; this explanation must include the fact that
sterilization is a final, irreversible procedure; a MAP eligible recipient must
be informed of the risks and benefits associated with the procedure;
(e) a MAP eligible recipient seeking
sterilization must also be instructed that their consent can be withdrawn at
any time prior to the performance of the procedure and that they would not lose
any other MAD benefits as a result of the decision to have or not have the
procedure; and
(f) a MAP eligible
recipient voluntarily gives informed consent to the sterilization procedure.
See
42 CFR Section
441.257(a); and
(g) a MAP eligible recipient's informed
consent to the sterilization procedure must be attached to the claim.
(2) Hysterectomies: MAD covers
only a medically necessary hysterectomy. MAD does not cover a hysterectomy
performed for the sole purpose of sterilization. See
42
CFR Section 441.253.
(a) Hysterectomies require a signed,
voluntary informed consent which acknowledges the sterilizing results of the
hysterectomy. The form must be signed by the MAP eligible recipient prior to
the operation.
(b) Acknowledgement
of the sterilizing results of the hysterectomy is not required from a MAP
eligible recipient who has been previously sterilized or who is past
child-bearing age as defined by the medical community. In this instance, the
PCP signs the bottom portion of the hysterectomy form which states the MAP
eligible recipient has been formerly sterilized, and attaches it to the
claim.
(c) An acknowledgement can
be signed after the fact if the hysterectomy is performed in an
emergency.
(3) Birthing
options services (BOP): MAD covers a MAP eligible pregnant recipient's labor
and delivery services at a New Mexico department of health (DOH) licensed birth
center through BOP. The BOP is an out-of-hospital birthing option for pregnant
women enrolled in the medicaid program who are at low-risk for adverse birth
outcomes. BOP services are provided by an eligible midwife that enrolls as a
BOP provider with human services department/medical assistance division
(HSD/MAD). The BOP services are specifically for basic obstetric care for
uncomplicated pregnancies and childbirth, including immediate newborn care that
is limited to stabilization of the baby during this transition. The program
does not cover the full scope of midwifery services nor replace pediatric care
that should occur at a primary care clinic.
(4) Other covered services: MAD covers
medically necessary methods, procedures, pharmaceutical supplies and devices to
prevent unintended pregnancy or contraception.
(5) Noncovered reproductive health care: MAD
does not cover the following specific services:
(a) sterilization reversal
services;
(b) fertility
drugs;
(c) in vitro
fertilization;
(d) artificial
insemination;
(e) hysterectomies
performed for the sole purpose of family planning;
(f) induced vaginal deliveries prior to 39
weeks unless medically indicated;
(g) caesarean sections unless medically
indicated; and
(h) elective
procedures to terminate a pregnancy.
E.
Nutritional services: MAD
covers medically necessary nutritional services which are based on
scientifically validated nutritional principles and interventions which are
generally accepted by the medical community and consistent with the physical
and medical condition of the MAP eligible recipient. MAD covers only those
services furnished by PCP, licensed nutritionists or licensed dieticians. MAD
covers the following services:
(1) Nutritional
assessments for a pregnant MAP eligible recipient and for a MAP eligible
recipient under 21 years of age through the early and periodic screening,
diagnosis and treatment (EPSDT) program. Nutritional assessment is defined as
an evaluation of the nutritional needs of the MAP eligible recipient based upon
appropriate biochemical, anthropometric, physical and dietary data to determine
nutrient needs and includes recommending appropriate nutritional
intake.
(2) Nutrition counseling to
or on behalf of a MAP eligible recipient under 21 years of age who has been
referred for a nutritional need. Nutrition counseling is defined as advising
and helping a MAP eligible recipient obtain appropriate nutritional intake by
integrating information from the nutrition assessment with information on food,
other sources of nutrients and meal preparation, consistent with cultural
background and socioeconomic status.
(3) Noncovered nutritional services: MAD
covers only those services furnished by a PCP, licensed nutritionist or
licensed dietician. MAD does not cover the following specific services:
(a) services not considered medically
necessary for the condition of the MAP eligible recipient as determined by MAD
or its designee;
(b) dietary
counseling for the sole purpose of weight loss;
(c) weight control and weight management
programs; and
(d) commercial
dietary supplements or replacement products marketed for the primary purpose of
weight loss and weight management; see 8.324.4 NMAC.
F.
Transplant
services: Non-experimental transplant services are covered. MAD covered
transplantation services include hospital, a PCP, laboratory, outpatient
surgical, and other MAD covered services necessary to perform the selected
transplantation for the MAP eligible recipient and donor.
(1) Due to special medicare coverage
available for individuals with end-stage renal disease, medicare eligibility
must be pursued by the provider for coverage of a kidney transplant before
requesting MAD reimbursement.
(2)
MAD covers the MAP eligible recipient's and donor's related medical,
transportation, meals and lodging services for non-experimental
transplantation.
(3) MAD does not
cover transplant procedures, treatments, use of a drug, biological product, a
product or a device which are considered unproven, experimental,
investigational or not effective for the condition for which they are intended
or used.
(4) A written prior
authorization must be obtained for any transplant, with the exception of a
cornea and a kidney. The prior authorization process must be started by the MAP
eligible recipient's attending PCP contacting the MAD UR contractor. Services
for which prior approval was obtained remain subject to UR at any point in the
payment.
G.
Dental
services: Dental services are covered as an optional medical service for
a MAP eligible recipient. Dental services are defined as those diagnostic,
preventive or corrective procedures to the teeth and associated structures of
the oral cavity furnished by, or under the supervision of, a dentist that
affect the oral or general health of the MAP eligible recipient. See
42 CFR Section
440.100(a). MAD also covers
dental services, dentures and special services for a MAP eligible recipient who
qualifies for services under the EPSDT program. See
42 CFR Section
441.55.
(1)
Emergency dental care: MAD covers emergency care for all MAP eligible
recipients. Emergency care is defined as services furnished when immediate
treatment is required to control hemorrhage, relieve pain or eliminate acute
infection. For a MAP eligible recipient under 21 years of age, care includes
operative procedures necessary to prevent pulpal death and the imminent loss of
teeth, and treatment of injuries to the teeth or supporting structures, such as
bone or soft tissue contiguous to the teeth.
(a) Routine restorative procedures and root
canal therapy are not emergency procedures.
(b) Prior authorization requirements are
waived for emergency care, but the claim can be reviewed prior to payment to
confirm that an actual emergency existed at the time of service.
(2) Diagnostic services: MAD
coverage for diagnostic services is limited to the following:
(a) for a MAP eligible recipient under 21
years of age, diagnostic services are limited to one clinical oral examination
every six months and upon referral one additional clinical oral examination by
a different dental provider every six months;
(b) one clinical oral examination every 12
months for a MAP eligible recipient 21 years and older; and
(c) MAD covers emergency oral examinations
which are performed as part of an emergency service to relieve pain and
suffering.
(3) Radiology
services: MAD coverage of radiology services is limited to the following:
(a) one intraoral complete series every 60
months per MAP eligible recipient; this series includes bitewing
x-rays;
(b) additional bitewing
x-rays once every 12 months per MAP eligible recipient; and
(c) panoramic films performed can be
substituted for an intraoral complete series, which is limited to one every 60
months per MAP eligible recipient.
(4) Preventive services: MAD coverage of
preventive services is subject to certain limitations.
(a) Prophylaxis: MAD covers for a MAP
eligible recipient under 21 years of age one prophylaxis service every six
months. MAD covers for a MAP eligible recipient 21 years of age and older who
has a developmental disability, as defined in 8.314.6 NMAC, one prophylaxis
service every six months. For a MAP eligible recipient 21 years of age and
older without a developmental disability, as defined in 8.314.6 NMAC, MAD
covers one prophylaxis service once in a 12 month-period.
(b) Fluoride treatment: MAD covers for a MAP
eligible recipient under 21 years of age, one fluoride treatment every six
months. For a MAP eligible recipient 21 years of age and older MAD, covers one
fluoride treatment once in a 12-month period.
(c) Fluoride varnish: MAD covers for a MAP
eligible recipient under 21 years of age, one fluoride varnish treatment every
six months.
(d) Molar sealants: MAD
only covers for a MAP eligible recipient under 21 years of age, sealants for
permanent molars. Each MAP eligible recipient can receive one treatment per
tooth every 60 months. MAD does not cover sealants when an occlusal restoration
has been completed on the tooth. Replacement of a sealant within the 60-month
period requires a prior authorization. For a MAP eligible recipient 21 years of
age and older, MAD does not cover sealant services.
(e) Space maintenance: MAD covers for a MAP
eligible recipient under 21 years of age fixed unilateral and fixed bilateral
space maintainers (passive appliances). For a MAP eligible recipient 21 years
of age and older, MAD does not cover space maintenance services.
(5) Restorative services: MAD
covers the following restorative services:
(a)
amalgam restorations (including polishing) on permanent and deciduous
teeth;
(b) resin restorations for
anterior and posterior teeth;
(c)
one prefabricated stainless steel crown per permanent or deciduous
tooth;
(d) one prefabricated resin
crown per permanent or deciduous tooth; and
(e) one recementation of a crown or
inlay.
(6) Endodontic
services: MAD covers therapeutic pulpotomy for a MAP eligible recipient under
21 years of age if performed on a primary or permanent tooth and no periapical
lesion is present on a radiograph.
(7) Periodontic services: MAD covers for a
MAP eligible recipient certain periodontics surgical, non-surgical and other
periodontics services subject to certain limitations:
(a) a collaborative practice dental hygienist
may provide periodontal scaling and root planning, per quadrant after diagnosis
by a MAD enrolled dentist; and
(b)
a collaborative practice dental hygienist may provide periodontal maintenance
procedures with prior authorization.
(8) Removable prosthodontic services: MAD
covers two denture adjustments per every 12 months per MAP eligible recipient.
MAD also covers repairs to complete and partial dentures.
(9) Fixed prosthodontics services: MAD covers
one recementation of a fixed bridge.
(10) Oral surgery services:
(a) simple and surgical extractions: MAD
coverage includes local anesthesia and routine post-operative care; erupted
surgical extractions are defined as extractions requiring elevation of
mucoperiosteal flap and removal of bone, or section of tooth and
closure;
(b) autogenous tooth
reimplantation of a permanent tooth: MAD covers for a MAP eligible recipient
under 21 years of age; and
(c) the
incision and the drainage of an abscess for a MAP eligible recipient.
(11) Adjunctive general services:
MAD covers emergency palliative treatment of dental pain for a MAP eligible
recipient. MAD also covers general anesthesia and intravenous sedation for a
MAP eligible recipient. Documentation of medical necessity must be available
for review by MAD or its designee. For a MAP eligible recipient under 21 years
of age, MAD covers the use of nitrous oxide analgesia. For a MAP eligible
recipient 21 years of age and older, MAD does not cover the use of nitrous
oxide analgesia.
(12) Hospital
care: MAD covers dental services normally furnished in an office setting if
they are performed in an inpatient hospital setting only with a prior
authorization, unless one of the following conditions exist:
(a) the MAP eligible recipient is under 21
years of age; or
(b) the MAP
eligible recipient under 21 years of age has a documented medical condition for
which hospitalization for even a minor procedure is medically justified;
or
(c) any service which requires a
prior authorization in an outpatient setting must have a prior authorization if
performed in an inpatient hospital.
(13) Behavioral management:Dental behavior
management as a means to assure comprehensive oral health care for persons with
developmental disabilities is covered. This code allows for additional
compensation to a dentist who is treating persons with developmental
disabilities due to the increased time, staffing, expertise, and adaptive
equipment required for treatment of a special needs MAP eligible recipient.
Dentists who have completed the training and received their certification from
DOH are eligible for reimbursement.
(14) Noncovered dental services: MAD does not
cover dental services that are performed for aesthetic or cosmetic purposes.
MAD covers orthodontic services only for a MAP eligible recipient under 21
years of age and only when specific criteria are met to assure medical
necessary. MAD does not cover the following specific services:
(a) surgical tray is considered part of the
surgical procedure and is not reimburse separately for tray;
(b) sterilization is considered part of the
dental procedure and is not reimbursed separately for sterilization;
(c) oral preparations, including topical
fluorides dispensed to a MAP eligible recipient for home use;
(d) permanent fixed bridges;
(e) procedures, appliances or restorations
solely for aesthetic, or cosmetic purposes;
(f) procedures for desensitization,
re-mineralization or tooth bleaching;
(g) occlusal adjustments, disking, overhang
removal or equilibration;
(h)
mastique or veneer procedures;
(i)
treatment of TMJ disorders, bite openers and orthotic appliances;
(j) services furnished by non-certified
dental assistants, such as radiographs;
(k) implants and implant-related services;
or
(l) removable unilateral cast
metal partial dentures.
H.
Podiatry and procedures on the
foot: MAD covers only medically necessary podiatric services furnished
by a provider, as required by the condition of the MAP eligible recipient. All
services must be furnished within the scope and practice of the podiatrist as
defined by state law, the New Mexico board of podiatry licensing requirements,
and in accordance with applicable federal, state, and local laws and rules. MAD
covers routine foot care if certain conditions of the foot, such as corns,
warts, calluses and conditions of the nails, post a hazard to a MAP eligible
recipient with a medical condition. MAD covers the treatment of warts on the
soles of the feet (plantar warts). Medical justification for the performance of
routine care must be documented in the MAP eligible recipient's medical record.
MAD covers the following specific podiatry services.
(1) Routine foot care: Routine foot care
services that do not meet the coverage criteria of medicare part B are not
covered by MAD. MAD covers services only when there is evidence of a systemic
condition, circulatory distress or areas of diminished sensation in the feet
demonstrated through physical or clinical determination. A MAP eligible
recipient with diagnoses marked by an asterisk(*) in the list below must be
under the active care of a physician or physician assistant (PA). to qualify
for covered routine foot care, and must have been assessed by that provider for
the specified condition within six months prior to or 60-calendar days after
the routine foot care service. A CNP, PA and a CNS do not satisfy the coverage
condition of "active care by a PCP".
(2) Common billed diagnoses: The following
list of systemic diseases is not all-inclusive and represents the most commonly
billed diagnoses which qualify for medically necessary foot care:
(a) diabetes mellitus*;
(b) arteriosclerosis obliterans;
(c) buerger's disease;
(d) chronic thrombophlebitis*;
(e) neuropathies involving the feet
associated with:
(i) malnutrition and vitamin
deficiency*;
(ii) malnutrition
(general, pellagra);
(iii)
alcoholism;
(iv) malabsorption
(celiac disease, tropical sprue);
(v) pernicious anemia;
(vi) carcinoma*;
(vii) diabetes mellitus*;
(viii) drugs or toxins*;
(ix) multiple sclerosis*;
(x) uremia (chronic renal disease)*;
(xi) traumatic injury;
(xii) leprosy or neurosyphilis;
(xiii) hereditary disorders;
(xiv) hereditary sensory radicular
neuropathy;
(xv) fabry's disease;
and
(xvi) amyloid
neuropathy.
(3) Routine foot care services: MAD covers
routine foot care services for a MAP eligible recipient who has a systemic
condition and meets the severity in the class findings as follows: one of class
A findings; or two of class B findings; or one of the class B findings and two
of the following class C findings:
(a) class A
findings: non-traumatic amputation of foot or integral skeletal portion
thereof;
(b) class B findings:
(i) absent posterior tibial pulse;
(ii) absent dorsalis pedis pulse;
and
(iii) advanced trophic changes
as evidenced by any three of the following: hair growth (decrease or increase);
nail changes (thickening); pigmentary changes (discoloring); skin texture
(thin, shiny); or skin color (rubor or redness);
(c) class C findings:
(i) claudication;
(ii) temperature changes (e.g., cold
feet);
(iii) edema;
(iv) paresthesias (abnormal spontaneous
sensations in the feet); or
(v)
burning.
(4)
Subluxated foot structure: Non-surgical and surgical correction of a subluxated
foot structure that is an integral part of the treatment of foot pathology or
that is undertaken to improve the function of the foot or to alleviate an
associated symptomatic condition, including treatment of bunions, is covered
when medical necessity has been documented. Treatment for bunions is limited to
capsular or bony surgery. The treatment of subluxation of the foot is defined
as partial dislocations or displacements of joint surfaces, tendons, ligaments
or muscles in the foot.
(5) Foot
warts: MAD covers the treatment of warts on the feet.
(6) Asymptomatic mycotic nails: MAD covers
the treatment of asymptomatic mycotic nails in the presence of a systemic
condition that meets the clinical findings and class findings as required for
routine foot care.
(7) Mycotic
nails: MAD covers the treatment of mycotic nails in the absence of a covered
systemic condition if there is clinical evidence of mycosis of the toenail and
one or more of the following conditions exist and results from the thickening
and dystrophy of the infected nail plate:
(a)
marked, significant limitation;
(b)
pain; or
(c) secondary
infection.
(8)
Orthopedic shoes and other supportive devices: MAD only covers these items when
the shoe is an integral part of a leg brace or therapeutic shoes furnished to
diabetics who is a MAP eligible recipient.
(9) Hospitalization: If the MAP eligible
recipient has existing medical condition that would predispose him or her to
complications even with minor procedures, hospitalization for the performance
of certain outpatient podiatric services may be covered.
(10) Noncovered podiatric services: A
provider is subject to the limitations and coverage restrictions that exist for
other medical services. MAD does not cover the following specific services or
procedures.
(a) Routine foot care is not
covered except as indicated under "covered services" for a MAP eligible
recipient with systemic conditions meeting specified class findings. Routine
foot care is defined as:
(i) trimming,
cutting, clipping and debriding toenails;
(ii) cutting or removal of corns, calluses,
or hyperkeratosis;
(iii) other
hygienic and preventative maintenance care such as cleaning and soaking of the
feet, application of topical medications, and the use of skin creams to
maintain skin tone in either ambulatory or bedfast MAP eligible recipient;
and
(iv) any other service
performed in the absence of localized illness, injury or symptoms involving the
foot.
(b) Services
directed toward the care or the correction of a flat foot condition are not
covered. Flat foot is defined as a condition in which one or more arches of the
foot have flattened out.
(c)
Orthopedic shoes and other supportive devices for the feet are generally not
covered. This exclusion does not apply if the shoe is an integral part of a leg
brace or therapeutic shoes furnished to a diabetic MAP eligible
recipient.
(d) Surgical or
nonsurgical treatments undertaken for the sole purpose of
correcting a subluxated structure in the foot as an isolated condition are not
covered. Subluxations of the foot are defined as partial dislocations or
displacements of joint surfaces, tendons, ligaments, or muscles of the
foot.
(e) MAD will not reimburse
for services that have been denied by medicare for coverage
limitations.
I.
Anesthesia: MAD covers
anesthesia and monitoring services which are medically necessary for
performance of surgical or diagnostic procedures, as required by the condition
of the MAP eligible recipient. All services must be provided within the limits
of MAD benefit package, within the scope and practice of anesthesia as defined
by state law and in accordance with applicable federal and state and local laws
and rules.
(1) When a provider performing the
medical or surgical procedure also provides a level of anesthesia lower in
intensity than moderate or conscious sedation, such as a local or topical
anesthesia, payment for this service is considered to be part of the underlying
medical or surgical service and will not be covered in addition to the
procedure.
(2) An anesthesia
service is not covered if the medical or surgical procedure is not a MAD
covered service.
(3) Separate
payment is not allowed for qualifying circumstances. Payment is considered
bundled into the anesthesia allowance.
(4) Separate payment is not allowed for the
anesthesia complicated by the physical status of the MAP eligible
recipient.
J.
Vision: MAD covers specific vision care services that are
medically necessary for the diagnosis of and treatment of eye diseases for a
MAP eligible recipient. MAD pays for the correction of refractive errors
required by the condition of the MAP eligible recipient. All services must be
furnished within the limits of the MAD benefits package, within the scope and
practice of the medical professional as defined by state law and in accordance
with applicable federal, state and local laws and rules.
(1) Vision exam: MAD covers routine eye
exams. Coverage for an eligible adult recipient 21 years of age and older of
age is limited to one routine eye exam in a 36-month period. An exam for an
existing medical condition, such as cataracts, diabetes, hypertension, and
glaucoma, will be covered for required follow-up and treatment. The medical
condition must be clearly documented on the MAP eligible recipient's visual
examination record and indicated by diagnosis on the claim. Exam coverage for a
MAP eligible recipient under 21 years of age is limited to one routine eye exam
in a 12-month period.
(2)
Noncovered vision services: MAD does not cover vision services that are
performed for aesthetic or cosmetic purposes. MAD covers orthoptic assessments
and treatments only when specific criteria are met to assure medical
necessity.
K.
Hearing: All audiology screening, diagnostic, preventive or
corrective services require medical clearance. Audiologic and vestibular
function studies are rendered by an audiologist or a PCP. Hearing aid dealers
and dispensers are not reimbursed for audiological, audiometric or other
hearing tests. Only licensed audiologists and PCPs are reimbursed for providing
these testing services.
L.
Client medical transportation: MAD covers expenses for
transportation, meals, and lodging it determines are necessary to secure MAD
covered medical or behavioral health examination and treatment for a MAP
eligible recipient in or out of his or her home community. See
42
CFR 440.170. Travel expenses include the cost
of transportation by long distance common carrier, taxicab, handivan, and
ground or air ambulance, all as appropriate to the situation and location of
the MAP eligible recipient. When medically necessary, MAD covers similar
expenses for an attendant who accompanies the MAP eligible recipient to the
medical or behavioral health examination or treatment. MAD reimburses a MAP
eligible recipient or the transportation provider for medically necessary
transportation subject to the following.
(1)
Free alternatives: Alternative transportation services which may be provided
free of charge include volunteers, relatives or transportation services
provided by a nursing facility (NF) or another residential center. A MAP
eligible recipient must certify in writing that he or she does not have access
to free alternatives.
(2) Least
costly alternatives: MAD covers the most appropriate and least costly
transportation alternatives suitable for the MAP eligible recipient's medical
or behavioral health condition. If a MAP eligible recipient can use a private
vehicle or public transportation, those alternatives must be used before the
MAP eligible recipient can use more expensive transportation
alternatives.
(3) Non-emergency
transportation service:
(a) MAD covers
non-emergency transportation services for a MAP eligible recipient who does not
have primary transportation to a MAD covered service and who is unable to
access a less costly form of public transportation.
(b) MAP eligible recipients released from
incarceration at a correctional facility may be transported by a New Mexico
medicaid transportation provider to a pharmacy to fill and retrieve prescribed
medication. The eligible recipient must have a valid prescription that is
qualified to be filled or re-filled at the time of their release from
incarceration.
(4) Long
distance common carriers: MAD covers long distance services furnished by a
common carrier if the MAP eligible recipient must leave his or her home
community to receive medical or behavioral health services. Authorization forms
for direct payment to long distance bus common carriers by MAD are available
through the MAP eligible recipient's local county income support division (ISD)
office.
(5) Ground ambulance
services: MAD covers services for a MAP eligible recipient provided by ground
ambulances when:
(a) an emergency which
requires ambulance service is certified by the attending provider or is
documented in the provider's records as meeting emergency medical necessity as
defined as:
(i) an emergency condition that
is a medical or behavioral health condition manifesting itself by acute
symptoms of sufficient severity (including severe pain) such that a prudent
layperson, who possesses an average knowledge of health and medicine, could
reasonably expect the absence of immediate medical attention to result in
placing the health of the MAP eligible recipient (or with respect to a pregnant
woman, the health of the woman or her unborn child) in serious jeopardy,
serious impairment to body function or serious dysfunction of any bodily organ
or part; and
(ii) medical necessity
for ambulance services is established if the MAP eligible recipient's condition
is such that the use of any other method of transportation is contraindicated
and would endanger the MAP eligible recipient's health.
(b) Scheduled, non-emergency ambulance
services: These services are covered when ordered by the MAP eligible
recipient's attending provider who certifies that the use of any other method
of non-emergency transportation is contraindicated by the MAP eligible
recipient's medical or behavioral condition.
(c) Reusable items and oxygen: MAD covers
non-reusable items and oxygen required during transportation. Coverage for
these items is included in the base rate reimbursement for a ground
ambulance;
(6) Air
ambulance services: MAD covers services for a MAP eligible recipient provided
by an air ambulance, including a private airplane, if an emergency exists and
the medical necessity for the service is certified by their attending provider.
(a) An emergency condition is a medical or
behavioral health condition manifesting itself by acute symptoms of sufficient
severity (including severe pain) such that a prudent layperson, who possesses
an average knowledge of health and medicine, could reasonably expect the
absence of immediate medical attention to result in placing the health of the
MAP eligible recipient (or with respect to a pregnant woman, the health of the
woman or her unborn child) in serious jeopardy, serious impairment to body
function or serious dysfunction of any bodily organ or part.
(b) MAD covers the following services for air
ambulances:
(i) non-reusable items and oxygen
required during transportation;
(ii) professional attendants required during
transportation; and
(iii) detention
time or standby time up to one hour without provider documentation; if the
detention or standby time is more than one hour, a statement from the attending
provider or flight nurse justifying the additional time is required.
(7) Lodging services:
MAD covers lodging services if a MAP eligible recipient is required to travel
to receive medical or behavioral health services and an overnight stay is
required due to medical necessity or cost considerations. If medically
justified and approved, in-state lodging is initially set for up to five
continuous days. For a longer stay, the need for lodging must be re-evaluated
by the fifth day to authorize up to an additional 15 days. Re-evaluation must
be made every 15-calendar days for extended stays, prior to the expiration of
the existing authorization. Approval of lodging is based on the attending
provider's statement of need. Authorization forms for direct payment to a MAD
approved lodging provider by MAD are available through local county ISD
offices. In addition, overnight lodging could include the following situations:
(a) a MAP eligible recipient who is required
to travel more than four hours each way to receive medical or behavioral health
services; or
(b) a MAP eligible
recipient who is required to travel less than four hours each way and is
receiving daily medical or behavioral health services and is not sufficiently
stable to travel or must be near a facility because of the potential need for
emergency or critical care.
(8) Meal services: MAD covers meals if a MAP
eligible recipient is required to leave his or her home community for eight
hours or more to receive medical or behavioral health services. Authorization
forms for direct payment to a meal provider by MAD are available through local
county ISD offices.
(9) Coverage
for attendants: MAD covers transportation, meals and lodging in the same manner
as for a MAP eligible recipient for one attendant if the medical necessity for
the attendant is certified in writing by the MAP eligible recipient's attending
provider or the MAP eligible recipient who is receiving medical service is
under 18 years of age. MAD only covers transportation services or related
expenses for a MAP eligible recipient and as certified, his or her attendant.
Transportation services and related expenses will not be reimbursed by MAD for
any other individual accompanying the MAP eligible recipient to a MAD covered
medical or behavioral health service.
(10) Coverage for a MAP eligible waiver
recipient: Transportation of a MAP eligible waiver recipient to a provider of a
waiver service is only covered when the service is occupational therapy,
physical therapy, speech therapy or an outpatient behavioral health
therapy.
(11) Out-of-state
transportation and related expenses: All out-of-state transportation, meals and
lodging must be prior approved by MAD or its designee. Out-of-state
transportation is approved only if the out-of-state medical or behavioral
health service is approved by MAD or its designee. Documentation must be
available to the reviewer to justify the out-of-state travel and verify that
treatment is not available in the state of New Mexico.
(a) Requests for out-of-state transportation
must be coordinated through MAD or its designee;
(b) Authorization for lodging and meal
services by an out-of-state provider can be granted for up to 30-calendar days
by MAD or its designee. Re-evaluation authorizations are completed prior to
expiration and every 30-calendar days, thereafter.
(c) Border cities: A border city is a city
within 100 miles of a New Mexico border (Mexico excluded). Transportation to a
border city is treated as in-state provider service. A MAP eligible recipient
who receives a MAD reimbursable service from a border area provider is eligible
for transportation services to that provider. See 8.302.4 NMAC, to determine
when a provider is considered an out-of-state provider or a border area
provider.
(12) Client
medical transportation fund: In a non-emergency situation, a MAP eligible
recipient can request reimbursement from the client medical transportation
(CMT) fund through his or her local county ISD office for money spent on
transportation, meals and lodging by the MAP eligible recipient; for
reimbursement from the CMT fund, a MAP eligible recipient must apply for
reimbursement within 30-calendar days from the date of appointment or the date
they are discharged from the hospital.
(a)
Information requirements: The following information must be furnished to the
ISD CMT fund custodian within 30-calendar days of the MAD approved provider
visit to receive reimbursement:
(i) submit a
letter on the provider's stationary which indicates that the MAP eligible
recipient kept the appointment for which the CMT fund reimbursement is
requested; for medical or behavioral health services, written receipts
confirming the date of service must be given to the MAP eligible recipient for
submission to the local county ISD office;
(ii) proper referral with original signatures
and documentation stating that the MAD services are not available within the
community from the MAD requesting provider, when a referral is
necessary;
(iii) verification of
current eligibility of the recipient for a MAD service for the month the
appointment and travel is made;
(iv) certification that free alternative
transportation services are not available and that the MAP eligible recipient
is not enrolled in a HSD contracted managed care organization (MCO);
(v) verification of mileage; and
(vi) documentation justifying a medical
attendant.
(b)
Preparation of referrals for travel outside the home community: If a MAP
eligible recipient must travel over 65 miles from his or her home community to
receive medical care, the transportation provider must obtain a written
verification from the referring provider or from the service provider
containing the following information for the provider to retain with their
billing records:
(i) the medical, behavioral
health or diagnostic service for which the MAP eligible recipient is being
referred;
(ii) the name of the out
of community medical or behavioral health provider; and
(iii) justification that the medical or
behavioral health care is not available in the home community.
(c) Fund advances in emergency
situations: Money from the CMT fund is advanced for travel only if an emergency
exists. An emergency is defined in this instance as a non-routine, unforeseen
accident, injury or acute illness demanding immediate action and for which
transportation arrangements could not be made five calendar days in advance of
the visit to the provider. Advance funds must be requested and disbursed prior
to the medical or behavioral health appointment.
(i) The ISD CMT fund custodian or a MAD FFS
coordinated service contractor or the appropriate utilization review (UR)
contractor verifies that the recipient is eligible for a MAD service and has a
medical or behavioral health appointment prior to advancing money from the CMT
fund and that the MAP eligible recipient is not enrolled in a HSD contracted
MCO;
(ii) written referral for out
of community service must be received by the CMT fund custodian or a MAD FFS
coordinated service contractor or the appropriate UR contractor no later than
30-calendar days from the date of the medical or behavioral health appointment
for which the advance funds were requested. If a MAP eligible recipient fails
to provide supporting documentation, recoupment proceedings are initiated; see
Section OIG-900, Restitutions.
(d) MAP Eligible recipients enrolled in a HSD
contracted MCO: Amember enrolled in HSD contracted MCO on the date of service
is not eligible to use the client medical transportation fund for services that
are the responsibility of the MAP eligible recipient's MCO.
(13) Noncovered transportation
services: Transportation services are subject to the same limitations and
coverage restrictions which exist for other services. A payment for
transportation to a non-covered MAD service is subject to retroactive
recoupment. MAD does not cover the following services or related costs of
travel:
(a) an attendant where there is not
the required certification from the MAP eligible recipient's medical or
behavioral health provider;
(b)
minor aged children of the MAP eligible recipient that are simply accompanying
them to medical or behavioral health services;
(c) transportation to a non-covered MAD
service;
(d) transportation to a
pharmacy provider with the exception for justice-involved MAP eligible
recipients who are released from incarceration at a correctional facility
within the first seven days of release; see 8.324.7 NMAC.
M.
Telehealth
services:
(1) Telemedicine visits: An
interactive HIPAA compliant telecommunication system must include both
interactive audio and video and be delivered on a real-time basis at the
originating and distant sites. If real-time audio/video technology is used in
furnishing a service when the MAP eligible recipient and the practitioner are
in the same institutional or office setting, then the practitioner should bill
for the service furnished as if it was furnished in person as a face to face
encounter. Coverage for services rendered through telemedicine shall be
determined in a manner consistent with medicaid coverage for health care
services provided through in person consultation. For telemedicine services,
when the originating-site is in New Mexico and the distant-site is outside New
Mexico, the provider at the distant-site must be licensed for telemedicine to
the extent required by New Mexico state law and regulations or meet federal
requirements for providing services to IHS facilities or tribal contract
facilities. Provision of telemedicine services does not require that a
certified medicaid healthcare provider be physically present with the MAP
eligible recipient at the originating site unless the telemedicine consultant
at the distant site deems it necessary.
(a)
Telemedicine originating-site: The location of a MAP eligible recipient at the
time the service is being furnished via an interactive telemedicine
communications system. The origination-site can be any of the following
medically warranted sites where services are furnished to a MAP eligible
recipient.
(i) The office of a physician or
practitioner.
(ii) A critical
access hospital (as described in section 1861 (mm)(1) of the Act).
(iii) A rural health clinic (as described in
1861 (mm)(2) of the Act).
(iv) A
federally qualified health center (as defined in section 1861 (aa)(4) of the
Act).
(v) A hospital (as defined in
section 1861 (e) of the Act).
(vi)
A hospital-based or critical access hospital-based renal dialysis center
(including satellites).
(vii) A
skilled nursing facility (as defined in section 1819(a) of the Act).
(viii) A community mental health center (as
defined in section 1861(ff)(3)(B) of the Act).
(ix) A renal dialysis facility (only for the
purposes of the home dialysis monthly ESRD-related clinical assessment in
section 1881(b)(3)(B) of the Act).
(x) The home of an individual (only for
purposes of the home dialysis ESRD-related clinical assessment in section
1881(b)(3)(B) of the Act).
(xi) A
mobile stroke unit (only for the purposes of diagnosis, evaluation, or
treatment of symptoms of an acute stroke provided in accordance with section
1834(m)(6) of the Act).
(xii) The
home of an individual (only for the purposes of treatment of a substance use
disorder or a co-occurring mental health disorder), furnished on or after July
1, 2019, to an individual with a substance use disorder diagnosis.
(xiii) The home of an individual when an
interactive audio and video telecommunication system that permits real-time
visit is used between the eligible provider and the MAP eligible
recipient.
(xiv) A School Based
Health Center (SBHC) as defined by section 2110(c)(9) of the Act.
(b) Telemedicine distant-site: The
location where the telemedicine provider is physically located at the time of
the telemedicine service. All services are covered to the same extent the
service and the provider are covered when not provided through telemedicine.
For these services, use of the telemedicine communications system fulfills the
requirement for a face-to-face encounter.
(c) Telemedicine reimbursement: MAD covers
both distant (where the eligible provider is located) as well as the
originating sites (where the MAP eligible recipient is located, if another
eligible provider accompanies the patient). If audio/video technology is used
in furnishing a service when the MAP eligible recipient and the practitioner
are in the same institutional or office setting, then the practitioner should
bill for the service furnished as if it was furnished in person and no
additional reimbursement is made.
(d) Telemedicine providers: Reimbursement for
professional services at the originating-site and the distant-site are made at
the same rate as when the services provided are furnished without the use of a
telecommunication system. In addition, reimbursement is made to the
originating-site for a real-time interactive audio/video technology
telemedicine system fee (where the MAP eligible recipient is located, if
another eligible provider accompanies the patient) at the lesser of the
provider's billed charge, or the maximum allowed by MAD for the specific
service of procedure. If the originating site is the patient's home, the
originating site fee should not be billed if the eligible provider does not
accompany the MAP eligible recipient. The MAP eligible recipient is not
reimbursed for their computer/internet.
(e) A telemedicine originating-site
communication system fee is covered if the MAP eligible recipient was present
at and participated in the telemedicine visit at the originating-site and the
system that is used meets the definition of a telemedicine system.
(2) Telephone visits: MAD will
reimburse eligible providers for limited professional services delivered by
telephone without video. No additional reimbursement is made to the
originating-site for an interactive telemedicine system fee.
(3) MAD will reimburse for services delivered
through store-and-forward. To be eligible for payment under store-and-forward,
the service must be provided through the transference of digital images,
sounds, or previously recorded video from one location to another; to allow a
consulting provider to obtain information, analyze it, and report back to the
referring physician providing the telemedicine consultation. Store-and-forward
telemedicine includes encounters that do not occur in real time (asynchronous)
and are consultants that do not require face-to-face live encounter between
patient and telemedicine provider.
(4) Noncovered telemedicine services: A
service provided through telemedicine is subject to the same program
restrictions, limitations and coverage which exist for the service when not
provided through telemedicine. Telemedicine services are not covered when
audio/video technology is used in furnishing a service when the MAP eligible
recipient and the practitioner are in the same institutional or office
setting.
N.
Pregnancy termination services: MAD does not cover the performance
of 'elective' pregnancy termination procedures. MAD will only pay for services
to terminate a pregnancy when certain conditions are met.
(1) Prior to performing pregnancy termination
services providers must complete and file in the MAP eligible recipient medical
record, a consent for pregnancy termination that includes written certification
of a provider that the procedure meets one of the following conditions:
(a) the procedure is necessary to save the
life of the MAP eligible recipient as certified in writing by a
provider;
(b) the pregnancy is a
result of rape or incest, as certified by the treating provider, the
appropriate reporting agency, or if not reported, the MAP eligible recipient is
not physically or emotionally able to report the incident; or
(c) the procedure is necessary to terminate
an ectopic pregnancy; or
(d) the
procedure is necessary because the pregnancy aggravates a pre-existing
condition, makes treatment of a condition impossible, interferes with or
hampers a diagnosis, or has a profound negative impact upon the physical,
emotional or mental health of the MAP eligible recipient.
(2) Psychological services: MAD covers
behavioral health services for a pregnant MAP eligible recipient.
(3) Oral medications: MAD covers oral
medications approved by the FDA have been determined a benefit by MAD for
pregnancy termination. MAD will cover oral medications when administered by a
provider acting within the scope of his or her practice board and
licensure.
(4) Informed consent:
Under New Mexico law, the provider may not require any MAP eligible recipient
to accept any medical service, diagnosis, or treatment or to undergo any other
health service provided under the plan if the MAP eligible recipient objects on
religious grounds or in the case of a non-emancipated MAP eligible recipient,
the legal parent or guardian of the non-emancipated MAP eligible recipient
objects.
(a) Consent: Voluntary, informed
consent by a MAP eligible recipient 18 years of age and older, or an
emancipated minor MAP eligible recipient must be given to the provider prior to
the procedure to terminate pregnancy, except in the following circumstances:
(i) in instances where a medical emergency
exists; a medical emergency exists in situations where the attending PCP
certifies that, based on the facts of the case presented, in his or her best
clinical judgment, the life or the health of the MAP eligible recipient is
endangered by the pregnancy so as to require an immediate pregnancy termination
procedure;
(ii) in instances where
the MAP eligible recipient is unconscious, incapacitated, or otherwise
incapable of giving consent; in such circumstances, the consent shall be
obtained as prescribed by New Mexico law;
(iii) in instances where pregnancy results
from rape or incest or the continuation of the pregnancy endangers the life of
the MAP eligible recipient;
(iv)
consent is valid for 30-calendar days from the date of signature, unless
withdrawn by the MAP eligible recipient prior to the procedure.
(b) Required acknowledgements: In
signing the consent, the MAP eligible recipient must acknowledge that she has
received, at least, the following information:
(i) alternatives to pregnancy
termination;
(ii) medical
procedure(s) to be used;
(iii)
possibility of the physical, mental, or both, side effects from the performance
of the procedure;
(iv) right to
receive pregnancy termination behavioral health services from an independent
MAD provider; and
(v) right to
withdraw consent up until the time the procedure is going to be
performed.
(c) Record
retention: A dated and signed copy of the consent, with counseling referral
information, if requested, must be given to the MAP eligible recipient. The
provider must keep the original signed consent with the MAP eligible
recipient's medical records.
(d)
Consent for a MAP eligible recipient under 18 years of age who is not an
emancipated minor, in instances not involving life endangerment, rape or
incest: Informed written consent for an non-emancipated minor to terminate a
pregnancy must be obtained, dated and signed by a parent, legal guardian, or
another adult acting 'in loco parentis' to the minor. An exception is when the
minor objects to parental involvement for personal reasons or the parent,
guardian or adult acting 'in loco parentis' is not available. The treating PCP
shall note the minor's objections or the unavailability of the parent or
guardian in the minor's chart, and:
(i)
certify in his or her best clinical judgment, the minor is mature enough and
well enough informed to make the decision about the procedure; in the
circumstance where sufficient maturity and information is not present or
apparent, certify that the procedure is in the minor's best interests based on
the information provided to the treating PCP by the minor; or
(ii) refer the minor to an independent MAD
behavioral health provider in circumstances where the treating PCP believes
behavioral health services are necessary before a clinical judgment can be
rendered on the criteria established in Paragraph (1) above; the referral shall
be made on the same day of the visit between the minor and the treating PCP
where consent is discussed; the independent MAD behavioral health provider
shall meet with the minor and confirm in writing to the treating PCP whether or
not the minor is mature enough and sufficiently informed to make the decision
about the procedure; in the circumstance where sufficient maturity and
information is not present or apparent, that the procedure is in the minor's
best interests based on the information provided to the independent MAD
behavioral health provider by the minor; this provider's written report is due
to the treating PCP within 72 hours of initial referral;
(iii) a minor shall not be required to obtain
behavioral health services referenced in Paragraph (2) above; however, if the
treating PCP is unable or unwilling to independently certify the requirements
established in Paragraph (1) above, the minor must be informed by the treating
PCP that written consent must be obtained by the parent, legal guardian or
parent 'in loco parentis' prior to performing the procedure; or, that the minor
must obtain a court order allowing the procedure without parental
consent.
O.
Behavioral health professional
services: Behavioral health services are addressed specifically in
8.321.2 NMAC.
P.
Experimental or investigational services: MAD covers medically
necessary services which are not considered unproven, investigational or
experimental for the condition for which they are intended or used as
determined by MAD. MAD does not cover experimental or investigational medical,
surgical or health care procedures or treatments, including the use of drugs,
biological products, other products or devices, except the following:
(1) Phase I, II, III or IV: MAD may approve
coverage for routine patient care costs incurred as a result of the MAP
eligible recipient's participation in a phase I, II, III, or IV cancer trial
that meets the following criteria. The cancer clinical trial is being conducted
with the approval of at least one of the following:
(a) one of the federal national institutes of
health;
(b) a federal national
institutes of health cooperative group or center;
(c) the federal department of
defense;
(d) the FDA in the form of
an investigational new drug application;
(e) the federal department of veteran
affairs; or
(f) a qualified
research entity that meets the criteria established by the federal national
institutes of health for grant eligibility.
(2) Review and approval: The clinical trial
has been reviewed and approved by an institutional review board that has a
multiple project assurance contract approved by the office of protection from
research risks of the federal national institutes of health.
(3) Experimental or investigational
interventions: Any medical, surgical, or other healthcare procedure or
treatment, including the use of a drug, a biological product, another product
or device, is considered experimental or investigational if it meets any of the
following conditions:
(a) current,
authoritative medical and scientific evidence regarding the medical, surgical,
or other health care procedure or treatment, including the use of a drug, a
biological product, another product or device for a specific condition shows
that further studies or clinical trials are necessary to determine benefits,
safety, efficacy and risks, especially as compared with standard or established
methods or alternatives for diagnosis or treatment or both outside an
investigational setting;
(b) the
drug, biological product, other product, device, procedure or treatment (the
"technology") lacks final approval from the FDA or any other governmental body
having authority to regulate the technology;
(c) the medical, surgical, other health care
procedure or treatment, including the use of a drug, a biological product,
another product or device is the subject of ongoing phase I, II, or III
clinical trials or under study to determine safety, efficacy, maximum tolerated
dose or toxicity, especially as compared with standard or established methods
or alternatives for diagnosis or treatment or both outside an investigational
setting.
(4) Review of
conditions: On request of MAD or its designee, a provider of a particular
service can be required to present current, authoritative medical and
scientific evidence that the proposed technology is not considered experimental
or investigational.
(5)
Reimbursement: MAD does not reimburse for medical, surgical, other health care
procedures or treatments, including the use of drugs, biological products,
other products or devices that are considered experimental or investigational,
except as specified as follows. MAD will reimburse a provider for routine
patient care services, which are those medically necessary services that would
be covered if the MAP eligible recipient were receiving standard cancer
treatment, rendered during the MAP eligible recipient's participation in phase
I, II, III, or IV cancer clinical trials.
(6) Experimental or investigational services:
MAD does not cover procedures, technologies or therapies that are considered
experimental or investigational.
Q.
Smoking/Tobacco cessation:
MAD covers tobacco cessation services for all MAP eligible recipients.
(1) Eligible medical, dental, and behavioral
health practitioner: Cessation counseling services may be provided by one of
the following:
(a) by or under the supervision
of a physician; or
(b) by any other
MAD enrolled health care professional authorized to provide other MAD services
who is also legally authorized to furnish such services under state
law;
(c) generally, eligible
practitioners would be medical practitioners, including independently enrolled
CNPs, behavioral health and dental practitioners; physician assistants and CNPs
not enrolled as independent MAD providers, and registered nurses and dental
hygienists may bill for counseling services through the enrolled entity under
which their other services are billed, when under the supervision of a dentist
or physician;
(d) counseling
service must be prescribed by a MAD enrolled licensed practitioner.
(2) Eligible pharmacy providers:
For rendering tobacco cessation services, eligible pharmacists are those who
have attended at least one continuing education course on tobacco cessation in
accordance with the federal public health guidelines found in the United States
department of health and human services; public health services' quick
reference guide for clinicians, and treating tobacco use and
dependence.
(3) Tobacco
cessation drug items: MAD covers all prescribed tobacco cessation drug items
for a MAP eligible recipient as listed in this section when ordered by a MAD
enrolled prescriber and dispensed by a MAD enrolled pharmacy. MAD does not
require prior authorization for reimbursement for tobacco cessation products,
but the items must be prescribed by a MAD enrolled practitioner. Tobacco
cessation products include, but are not limited to the following:
(a) sustained release buproprion
products;
(b) varenicline tartrate
tablets; and
(c) prescription and
over-the-counter (OTC) nicotine replacement drug products, such as lozenges,
patches, gums, sprays and inhalers.
(4) Covered services: MAD makes reimbursement
for assessing all MAP eligible recipient's tobacco dependence including a
written tobacco cessation treatment plan of care as part of an evaluation and
management (E&M) service, and may bill using the E&M codes. MAD covers
face-to-face counseling when rendered by an appropriate provider. The
effectiveness of counseling is comparable to pharmacotherapy alone. Counseling
plus medication provides additive benefits. Treatment may include prescribing
any combination of tobacco cessation products and counseling. Providers can
prescribe one or more modalities of treatment. Cessation counseling session
refers face-to-face MAP eligible recipient contact of either
(a) intermediate session (greater than three
minutes up to 10 minutes); or
(b)
intensive session (greater than 10 minutes).
(5) Documentation for counseling services:
Ordering and rendering practitioners must maintain sufficient documentation to
substantiate the medical necessity of the service and the services rendered,
which may consist of documentation of tobacco use. The rendering practitioner
must maintain documentation that face-to-face counseling was prescribed by a
practitioner, even if the case is a referral to self, consistent with other
NMAC rules and other materials.
(6)
Limitations on counseling sessions: The services do not have any limits on the
length of treatment or quit attempts per year. The program also allows
participants to try multiple treatments and does not impose any requirement to
enroll into counseling. During the 12-month period, the practitioner and the
MAP eligible recipient have flexibility to choose between intermediate or
intensive counseling modalities of treatment for each session.
R.
Screening, brief
intervention and referral to treatment (SBIRT) service: SBIRT is a
community-based practice designed to identify, reduce and prevent problematic
substance use or misuse and co-occurring mental health disorders as an early
intervention. Through early identification in a medical setting, SBIRT services
expand and enhance the continuum of care and reduce costly health care
utilization. The primary objective is the integration of behavioral health with
physical health care. SBIRT is delivered through a process consisting of
universal screening, scoring the screening tool and a warm hand-off to a SBIRT
trained professional who conducts a face-to-face brief intervention for
positive screening results. If the need is identified for behavioral health
treatment, the certified SBIRT staff, with the eligible recipient's approval,
assists in securing behavioral health services. Only a physical health office,
clinic, or facility who has been certified by a HSD approved SBIRT trainer and
uses the approved healthy lifestyle questionnaire (HLQ) can complete the
screen. The physical office, clinic or facility must be the billing provider,
not the individual practitioner. All practitioners must be SBIRT certified and
are employees or contractors of a SBIRT physical health office, clinic or
facility. See the SBIRT policy and billing manual for detailed description of
the service and billing requirements.
S.
Other services: Other covered
and noncovered services including hospitalization and other residential
facilities, devices for hearing and vision correction, behavioral health
services, home and community based services, EPSDT services, case management
and other adjunct and specialty services are described in other NMAC
rules.